Free Wellness Evaluation by your Herbalife Coach

If you need some assistance and are not getting the overall results that you were
looking for, this free evaluation is for you.

Together we can take some time to look at the factors that could help improve your
health and well-being. You will learn all about your current wellness and how you can
improve the areas that are important to you.

Simply fill out this questionnaire or Call  (412)-567-0358     Its FREE!!
Health and Lifestyle Questionnaire
1. Which of these words best describes your own lifestyle?
Calm
 Active
 Stressed
2. Do you think you get 100% of the daily nutrition needed for good
health?
Yes
 No
 Sometimes
3. Do you take nutritional supplements (vitamins/minerals/proteins)?
Yes
 Never
 Sometimes
4. Do you experience a loss of energy during the day?
Yes
 No
 Occasionally
5. Do you, or does any member of your family or friends need to lose,
gain or maintain weight?
Lose weight
 Gain weight
Maintain weight
 Can’t say for certain
6. Approximately how much weight do you/they need to lose?
You :
 lbs.
Family :
 lbs.
 lbs.
 lbs.
Friends :
 lbs.
 lbs.
 lbs.
7. Have you tried diet programs in the past?
Yes
 No
Which ones?:
8. Do you eat a variety of healthy foods from the basic food groups
every day?
Yes
 No
9. If no, why not?
Not enough time for shopping/preparation
Too expensive
 Too complicated
10. Are you interested in learning about a nutritional program to control
weight while still eating the foods you like, without feeling hungry?
Yes
 No
11. Would you prefer further information to be sent to your home, office
or email?
Yes
 No
Your Name :
Email :
Phone :